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QIPS TIPS #18: Why We Don't Apologize and #19: Something Bad Just Happened



 QIPS TIPS #18:  Why We Don’t Apologize

Shari WelchThe words “I’m Sorry” are the most commonly uttered words in any language! So why are they so difficult to utter to patients and families?

What are some challenges in implementation of the medical apology?
Perhaps the biggest challenge in the adoption of the medical apology as an ideology and a strategy comes from the culture of healthcare itself. Esteemed Harvard physician and writer, Lucien Leape notes that in recent years, many hospitals have made great strides in increasing transparency, taking responsibility for adverse events, and providing apology training and support for professionals. Some organizations have worked in collaboration with national advocacy groups to develop formal programs that provide patient and caregiver support after adverse events. Increasing numbers of hospitals are developing their own support programs and full disclosure, apology, and early compensation policies.

Why haven’t all hospitals done it? Leape posits that the most obvious reason for executives’ reluctance is the lack of adequate stakeholder pressure to do so. In addition, many executives and physicians don’t accept the concept that errors and accidents result from systems failures. And even if they accept this premise, they fail to make the obvious connection that therefore the primary responsibility for the failures is theirs.
Another big constraint to apology is cultural and begins with the physician. Boothman and colleagues thoroughly cover the deny and defend method, the traditional approach used after adverse events. Lawyers are prone to warning doctors that patients and families may see an apology as an admission of guilt when the physician may sincerely attempt to show compassion. It becomes hard to show that apology may reduce risk: How do you measure lawsuits that do not occur?
Eschewing apology is a choice driven not by data but by fear and anecdote. Though it is now politically correct to apologize and admit mistakes, behind closed doors the old dialogues continue. Insurers tell their physician clients “Never use the words ‘I’m sorry.’” Leape points out that in addition to such outdated mindsets, for years hospital lawyers have counseled against honest, full disclosure and apology, claiming that they increase the likelihood of being sued and of losing in court. In Leape’s view, “financial considerations have trumped morality.”

Risk management has also contributed to the constraints to apology. Until now, most risk managers have subscribed to the notion that apology is inappropriate unless the error was preventable and the organization is responsible for it. The message is that this statement is a confession of guilt by the organization and physicians and staff are cautioned about making such statements. But as Woods (2007) points out, we say, “I’m so sorry” when we learn of a death in someone’s family or other bad news. Even though we have no connection to it or liability for it, we express this most human of responses. Apology has nothing to do with causation.

The Sorry Works! Coalition, founded by my fellow commentator Doug Wojcieszak, provides resources for organizations launching disclosure and apology programs and provides a list of states with apology laws. Such statutes let doctors and providers apologize and express grief, without these statements later being used against them in court.

The next time you have an event in the ED (a very common site in healthcare for sentinel events and mistakes by the way) try an apology.  Don’t be afraid, it really can set you free!  In QIPS TIPS #19 We will offer the communication tools to get you started.


QIPS TIPS # 19: Something Bad Just Happened
Shari Welch MD

How should we approach patients that have been harmed?

Remember, apology is most effective at the front lines and in the clinical trenches. More than 80 percent of malpractice claims are due to poor patient–provider relationship (CITATION). Providers who have good communication skills and speak to their patients authentically have lower rates of being sued. Risk has so much to do with the interpersonal relationships between patients and providers and relatively little to do with the quality of the care that was rendered.

The field is moving increasingly toward early disclosure of a medical adverse event or error, with full disclosure of the situation’s facts. Patients and their families want information and in particular want reassurance that they will recover and that efforts are being made to prevent the problem from occurring again. Organizations with established processes for managing such episodes help patients and their families cope and also help staff recover.

Training providers and leadership in apology and disclosure has been successful at the University of Michigan (as Boothman and colleagues detail) and the Lexington VA Medical Center. Although the organization and insurers can’t micromanage the interpersonal relationship between provider and patient, they can get out of the way and provide basic principles and approaches.

Another critical element in the disclosure and apology process is timeliness of response and compensation. The hospital needs to develop a policy, a process, training, and support mechanisms around these factors. According to Leape, hospitals will need to put resources and money behind these programs and prepare to provide financial restitution. He reminds us, “Apology without compensation is a sham. As Lazare has taught, the essential components of meaningful apology are taking responsibility, showing remorse, and making restitution.”

Teaching providers communication skills and the proper language of apology is also integral to a disclosure and apology program. Box 1. gives examples of language to use when adverse events occur in healthcare involving the critical elements we know patients and families want to hear from us: Recognition, regret, responsibility, remedy and an indication that you will remain involved in their case. Similar scripts could be developed and disseminated by risk management departments. Some providers will need coaching in how to deliver the script.

Box 1. Examples of Scripting 

• “I’m sorry that this has happened to you, and I want to assure you I’ll do everything possible to learn how it occurred.” Recognition
• “I really regret that this happened. I know it is not what either of us wanted or expected, and I want you to know how sorry I am for what you are going through.”
    Regret
• “I am responsible for your care and I will find out what happened, and, if possible, why it happened. I will keep you posted of what I learn and how it can be used
    to prevent this from happening again. At this point I am not sure if I would have done anything differently, but I
    intend to explore that thoroughly.” Responsibility  
• “It is still early to tell, but I don’t think you will have any long-term health problems. I will verify this over time. I want you to know the problem occurred because of
    a communication error, and I am researching changes that will keep it from happening again.” Clinical remedy
• “I am responsible for your care and will be completely available to you.  Here is my card; please call me directly if you have any problems.” Remaining engaged

Source: Adapted from Woods (2007).

Since 85% of human communication is non-verbal, how you say your apology is at least as important as what you say.  Box 2 is a nice set of points about your communication strategy during this encounter.

Box 2. Tips for Communication During an Apology

•  Make full eye contact
•  Keep your hands relaxed at your sides (do not cross your arms across your chest)
•  Sit down; consider sitting on the edge of the patient’s bed if she gives you permission to do so
•  Gesture with open hands (avoid pointing)
•  Give the patient and family ample time to ask questions


References

•         Leap, Lucien, Errors in Medicine, JAMA, 1994
•         Woods, Michael. Healing Words: The Power of Apology in Medicine, Joint Commission Resources, Oakbrook Terrace, 2007
•         Leap, Lucien, Medical Apology Programs, Frontiers in Health Services  Management, 2012
•         Conway J, Federico F, Stewart K, Campbell M. Respectful Management of Serious Clinical Adverse Events (Second Edition). IHI Innovation Series White.
          Paper, Institute for Healthcare Improvement; 2011. 

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